4 Clark County Fire Fighter FatalityCrews operating at the scene of a commercial dice factory fireHeavy smoke and fire conditionsAll crews are instructed to utilize standard PPESCBA are used by all respondersClark County Las Vegas Nev.We have been trained with tactical theory from yesterday. With the addition of plastics, synthetics, and natural fibers these materials burn hotter and the toxic by-products that are given off during and after the fire are more deadlier.I use the analogy is that our bodies are like sponges. We will absorb vapors and gases into our systems some of which will be excreted or metabolized and some unfortunately will not.More emphasis needs to be place on fire behavior, smoke reading, toxicology, building construction, health and safety.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 4/40

5 Clark County Fire Fighter FatalityWhat are some of the hazards present?As a Incident Commander, what types of injuries or conditions may you expect?Smoke- particulate matter, heated gases, irritants such as hydrochloric acid, sulfur dioxide, ammoniaAsphyxiates such as carbon dioxide and toxins such as hydrogen sulfide and hydrogen cyanide.Both CO and CN are very likely to be two of the most prevalent gases.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 5/40

6 Clark County Fire Fighter FatalityAll crews are ordered out of the structure.As crews leave the factory, they remove their SCBA masks.A Fire Captain removes his mask as he walks out of the smoke. He collapses outside the structure.He is in cardiac arrest.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 6/40

7 Clark County Fire Fighter FatalityThe Captain did not survive his injuriesCoroner ruled this fatality due to cyanide toxicity.Clark County Fire DepartmentCaptain Frank E. Testa, April 11, 1970The U.S. Fire Academy and the IAFF have for years utilized the same NIOSH firefighter fatality statistics to assist in driving the Firefighter Wellness initiatives. These initiatives are based on the statistics that show approximately 50 % of fireground fatalities are caused by cardiac arrest secondary to poor fitness levels. One of the most recent theories currently being evaluated by the IAFC is the possibility of cyanide poisoning causing some cardiac arrests.Early symptoms can masquerade as exhaustion(poor fitness) or a cardiac arrest. These secondary symptoms may be misconstrued as a singular event initiated by a myocardial infarction when, in fact, the problem may have been caused by undiagnosed cyanide poisoning.Cardiac abnormalities induced by cyanide are not limited to immediate on-scene affects, and may be causing some of the more than heart attacks that firefighters sustain each year in the line of duty.Given the fact that cardiac abnormalities may not be present immediately, many off-duty heart attacks may also be related to cyanide exposures at fires.There is evidence that exposures to cyanide poisoning may occur up to 8 days after the exposure.EKG changes can be observed 2-3 weeks after fire related cyanide exposure.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 7/40

8 In 2005, there were 1,602,000 fires reported in U.S.2005 FIRE STATISTICSIn 2005, there were 1,602,000 fires reported in U.S.511,000 structure fires3,105 civilian deaths15,325 civilian injuries$9.2 billion in property damage87 firefighter deaths in all types of fires>4000 firefighters injured by smoke inhalationIt is estimated up to 80% of all fire fatalities are attributable to smoke inhalationDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 8/40

9 Toxic composition of smoke varies from fire to fireANATOMY OF FIRE SMOKEToxic composition of smoke varies from fire to fireNature of the burning materialsTemperatureOxygen levelVentilationConditions of high temperature and low oxygen enhance degradation of synthetics quickening chemical releaseThe degradation of these materials happens long before flame ignition begins.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 9/40

11 CYANIDE TOXICITY IN SMOKEHistorically, carbon monoxide asphyxiation has been considered the primary cause of deaths of those overcome by smokeFocus of gas monitoringThere is mounting evidence that hydrogen cyanide is directly responsible for many more deaths than previously assumedCumulative effect with CO worse than either individuallyHCN monitoring devices needs to be added to the monitoring capabilities.Documentation of such exposures need to be captured and used for further research.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 11/40

12 “ Cyanide toxicity from smoke inhalation in a structural or enclosed space fire is the most likely cause of cyanide toxicity that EMS & fire professionals will encounter” JEMS Communications Summer 2004With mounting evidence building this is becoming a critical situation in both acute and chronic exposure illnesses for fire and ems personnel.Unless proper PPE is used this will be a growing problem.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 12/40

14 Cyanide production in a fireCYANIDE PRODUCING MATERIALSCyanide production in a fireHydrogen cyanide is produced by incomplete combustion of nitrogen and carbon containing substances (-C≡N)Natural Fibers (wool, silk, cotton, paper)Synthetic polymers (nylon, polyurethane)Synthetic rubberMelamine (resins for molding, laminating, etc.)HCN, a colorless or pale blue compound occasionally found to have a bitter almond-like odor.In order to detect HCN by smell, our bodies must have a particular gene to do so. The gene is absent from % of the general population. So even if you do have the gene you may not be able to detect the odor of HCN due to other odors in the air.Molecule composed of a carbon atom bound to a nitrogen atom by three strong bonds -C≡NDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 14/40

15 Synthetic polymers found extensively in structuresHCN RELEASING POLYMERSSynthetic polymers found extensively in structuresInsulationCushioningCarpetsBedding (mattresses and pillows)Building materialsMaterials can burn up to 2-3 times hotter and faster than natural materialsQuicker flashovers increase speed of HCN release ---Synthetic polymers release large quantities of cyanide.Smoldering materials can release even higher levels of cyanide.This is a perfect reason for SCBA usage.DRAEGER SAFETY Cyanide in Fire OperationsMarch 28, • 15/40

16 Other small scale uses: Sources of CyanideOther small scale uses:- Photography labs Blue printing Engraving computer chips - Cleaning or reconditioning of jewelry - Found at clandestine drug labs - manufacturing phencyclidine (PCP)Atmospheric monitoring is an absolute essential tool to have on all fire/ems related responses.Potassium Ferricyanide- powder form used in toners for photographic and blue printing uses.Copper, gold, silver cyanide used in the etching of the pin making connection with the terminal. This prevents corrosion.Sodium and Potassium used in electroplating in jewelryPotassium cyanide found at clandestine drug labsTransportation vehicle interiorsPesticides usagesX-ray film recoveryAcrilonitrile used in artificial nail adhesiveDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 16/40

18 KEY CYANIDE STUDIESFinal Conclusion: Cyanide and carbon monoxide were both important determinants of smoke inhalation-associated morbidity and mortality Cyanide concentrations were directly related to the probability of death Cyanide may have dominated over CO as a cause of death in some fire victims Cyanide and CO may have potentiated the toxic effects of one anotherDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 18/40

19 THE STATION NIGHTCLUB FIREMost notorious incident of deaths from toxic mix of hydrogen cyanide and carbon monoxide was at West Warwick Rhode Island nightclub fire Feb 20,2003Pyrotechnics instantly set substandard sound suppressing foam to sheet of flameHCN and CO levels soar and people are quickly overcome by the smoke100 deaths and 200 injuriesPolystyrene spray on insulation for sound barrierDeaths were believed to be from T.V. production crews inpeedeing the exit point out of the building.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 19/40

20 The Station Night Club FireNational Institute of Standards and Technology “the high temperatures, low oxygen, high carbon monoxide, and high HCN levels within the test room in the absence of a sprinkler all contributed to a non-tenable condition within 90 seconds after ignition.”Health care providers at all levels of this tragedy did not consider HCN exposure during course of treatment for the surviving victims.New England Journal of Medicine published report: “despite the signs and symptoms indicating CN poisoning, the victims were treated with standard modalities for burns and CO toxicity”DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 20/40

21 Cyanide Poisoning Of Providence Rhode Island Firefighters March 2006Thursday March :31 hrs Broad StreetProvidence Rhode Island Firefighters responded to a fast food restaurant relatively uneventful Engine 3’s crew member experienced symptoms of headache, dizziness, difficulty breathing a cough, and at times talking incoherently Transported to Rhode Island Hospital Level 1 Trauma Center. Tested for HCN to find high levels of blood cyanide at 57 ug/dl Placed on antidote therapyUpon learning of Engine 3’s firefighter department contacted all members responding to the call members sought medical attention members went to Rhode Island Hospital found to have whole blood cyanide levels above 20 ug/dlInformation of facts obtain from the Providence Fire Department Local 799after action report May 30, 2006Investigation team revealedBroad Street:Rigid foam insulation panels were located in the ceiling and roof assembly.Roof consisted of a rubber outer membrane sealed with black tar like adhesive.Portions of the roof contained asphalt shingles.The interior contained fiber reinforced plastic.75% of the members at the Broad street fire were complaining of headaches and 85% of the members complained of weakness and fatigueDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 21/40

22 Cyanide Poisoning of Providence Firefighters March 2006March 23, :35 hrs Knight StreetProvidence Rhode Island firefighters responded to a fire in a six-unit residential apartment Fire in a different part of the city after shift change. Most of the personnel from fast food restaurant relived No injuries reportedMarch 24, :07 hrs. 70 Ralph StreetProvidence Rhode Island firefighters responded to a house fire All firefighter responding to Ralph St. had previously responded to Knight Street fire At 02:23 hrs. Firefighter Kenneth Baker collapsed at the scene suffering a heart attack Immediately resuscitated and transported to Rhode Island HospitalKnight street fire revealed:Burning contents of crib mattress, plastic bags of clothing, plastic toys, electronic devices(television, stereo), mattress and box spring.Fire area was carpeted and had a foam padding underneathRalph Street fire was:Contained to the bathroom that contained a fiberglass tub that melted, and numerous plastic items.Heat from the fire was sufficient enough to melt plastic items in the adjacent kitchen areaThe rescue technician witnessed F.F. Baker lean against the drivers door of Engine 6, and slide down coming to rest against the front wheelF.F. Baker was found to be in ventricular fibrillation and defibrillated twice by medical personnel on the sceneDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 22/40

23 Cyanide Poisoning of Rhode Island Firefighters March 2006In light of the cyanide cases from the previous day testing was conducted on Firefighter Baker. Lab test showed that FF. Baker had whole blood cyanide level of 66ug/dlAfter consulting with doctors at Rhode Island Hospital, all members who responded to any of the three fires were instructed to go to Rhode Island Hospital if they experienced any symptoms to cyanide poisoning members sought medical care had their cyanide levels tested 8 members tested high (above 20 ug/dl) for cyanideFire Chief David Costa appointed a five member committee to investigate the causes of cyanide poisoning, review existing policies and procedures, and make recommendations to prevent this from happening again.F.F. Bakers gear was secured and analytically wiped testedHelmet – total cyanide present ug entire outer surfaceMask- total cyanide present <0.5 ug entire surfaceCoat- cyanide per sq. inch <0.5 ug/ft2 4 ft2 (back)Pants- cyanide per sq. inch < 2.0 ug/ft2 (left pant leg)Boots- total cyanide present < 0.5 ug entire outer surface (left boot)Gloves- total cyanide present < 0.5 ug entire outer surface left hand)Decontamination of gear after each fireSCBA masks cleanedMask bags washedShower after each fireRisk Management issuesDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 23/40

25 Small amounts of cyanide are present in the environment and in humans. CYANIDE DOSESSmall amounts of cyanide are present in the environment and in humans.Normal levels of whole blood are believed to be between 0 to 20 micrograms per deciliter (ug/dl).Cyanide levels as low as 50 ug/dl in the blood have proven to be toxic, and blood cyanide levels of 250 – 300 ug/dl fatal.With a half-life of one hour, cyanide is short lived in the blood stream. Standards in the procedures for collection of whole blood samples such as: carboxyhemoglobin saturation methemoglobin content of sampled blood -time between blood sampling and assay storage temperature of blood samples on the measured concentration of cyanide can complicate the interpretation of assay results or introduce sources of errors.Small amounts of cyanide present in the environment include:Bacteria, insects, plants, and animals naturally. They can form, degrade, excrete the compound used as a defense against insects.Natural sources: almonds, cherries, various seeds (peaches, apples)Deciliter = 1/10 of a literHC inhaled into the blood stream in a matter of seconds has a half-life in the blood of approximately one-hour.If a member has blood cyanide level of 100 ug/dl immediately after an exposure, one hour later the level should be 50 ug/dl, two hours later 25 ug/dl three hours later 12.5 ug/dl four hours later 6.25 ug/dl, five hours later ug/dl , six hours later ug/dl.Only eight laboratories in the country that performs whole blood cyanide tests and doctors with out in-house testing capability may have to wait up to a week for the results. Quest Diagnostic Labs is a local source.Certain laboratory test which can be performed at a hospital include: elevated venous blood oxygen concentration elevated plasma lactate concentrations metabolic acidosis (Cyanide Poisoning Treatment Coalition)DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 25/40

26 ACUTE CYANIDE POISONINGHydrogen cyanide is a cellular asphyxiantInhaled HCN inhibits enzyme system responsible for cell respiration (oxygen utilization by cell)Cessation of cell respiration makes normal cell function impossible, leading to cell mortalityThere is no quick test that allows on-site confirmation of HCN toxicityThere are some signs that can lead to assumption of HCN exposure and administration of countermeasuresDisorientation and weakness/DrowsinessShortness of breath and chest tightness(Tachypnea, Dyspnea Tachycardia)HeadacheBright red discoloration in skinSmell of almonds on breathSoot around mouth and nose/burnsCarbonaceous sputumTachypnea-abnormally fast breathingDyspnea- difficulty breathingTachycardia-cardiac arrhythmia which refers to rapid beating of the heartRescue or escape from a smoke filled enclosed space.Soot around mouth and noseCarbonaceous sputumBurns around mouth and noseDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 26/40

28 Acute Cyanide PoisoningSignificance for advocates of “sucking the carpet” - carpet fibers are a large source of HCN - fumes develop long before carpet catches fire.Quantitative decomposition long period of time when gas is emitted without the warning presence of flame decomposition stage of the fire is more toxic than those emitted during actual burning decomposition stage is the real killer because of its high toxicity and long period of time between attainment of quantitative decomposition temperature and ignition temperatureClosed room and content compartment fire the entire atmosphere (floor-to-ceiling) is heating up and off-gassing towards ignition.While heat is generating on an object gasses are being emitted and when there is the right mixture of gas to oxygen ratio ignition occurs. During this time the toxic byproducts are becoming concentrated enough to incapacitate any one who may be inside the structure.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 28/40

29 Acute Cyanide PoisoningNarcotic effects of HCN -blamed for bizarre and irrational behavior - instances where victims, including firefighters fought with rescuers until becoming totally overcome by the smoke.Southwest Supermarket fire Phoenix Arizona - Brett Tarver rescue teams were hampered on several occasions succumbed to the environment and pulled through debris and out of the building.Hypoxia –lack of oxygen to the brainCNS- excitementDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 29/40

30 Effect DOSE MAKES THE POISON HCN LETHALITY Concentrations mg/m3 PPMImmediately Lethal200mg/m ppmLethal after 10 minutes150mg/m ppmLethal after 30 minutesmg/m ppmHighly dangerous (Fatal) after minutes20-40mg/m ppmLight symptoms after several hoursPersons whose clothing or skin is contaminated with cyanide can secondarily contaminate response personnel by direct contact or through off-gassing vapor.Hydrogen cyanide is absorbed well by inhalation and can produce death within minutes.Substantial absorption can occur through intact skin if vapor concentration is high.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 30/40

32 ACUTE CYANIDE POISONINGRecently has there been first FDA approved cyanide treatment, Hydroxocobalamin, that can safely be administered at fire sceneDetoxifies CN by binding it to form cyanocobalamin (B12)Marketed as Cyanokit®Used in France for 10 yearsPreviously, only supportive measures were available on site100% oxygen applicationSodium bicarbonate to counter metabolic acidosisCardiopulmonary support and anticonvulsantsExisting antidote involved nitrates that needed to be monitored under hospital care to avoid lethality when combined with CO Taylor Kit Lilly Kit Pasadena KitThe current treatment for smoke inhalation is to remove the victim from source of exposure, administer ABC’s, administer 100% oxygen and vitals.Based upon results of these studies, new thinking for treatment of smoke inhalation victims is now being focused toward cyanide poisoning.The Paris, France Fire Department does carry antidote kits specifically for smoke inhalation victims called Cyanokit.By protocol in Paris, if a victim has soot in the nose or mouth and suffers an altered level of consciousness, the Cyanokit is used.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 32/40

33 PHOENIX OVERHAUL STUDIESRemoval of respiratory equipment during overhaul can potentially expose firefighters to a variety of toxic gasesOverhaul phase of fire lasts an average of 30 minutesLiberated gases, vapors and particulates may remain in overhaul environment for extended periods of timeVapors may use airborne respirable particulates as entry vehicle into firefighters’ lungsMaximum concentrations of selected contaminants can exceed occupational exposure limitsAdverse health effects may occur from exposure to mixture of products even if individual components are below exposure limitsMonitoring CO concentrations alone should not be used to predict presence of other contaminants found in the overhaul environmentBolstad-Johnson, et alDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 33/40

34 Conclusions of Phoenix StudiesPHOENIX OVERHAUL STUDIESConclusions of Phoenix StudiesWithout the use of respiratory protection, firefighters are overexposed to irritants, chemical asphyxiates and carcinogensRespiratory protection is recommended during fire overhaulSCBA should be utilized in atmospheres with CO > 150 ppmAPRs may be considered when CO < 150 ppm, but additional studies to confirm effectiveness in overhaul operations are recommendedNIOSH cartridges for APR don’t provide CO protection150 ppm equates to avg ppm exposure based on 60 minute exposure and 8-hour working day (TLV= 25 ppm)- Post-fire fuels are still off-gassing, SCBA’s should be used.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 34/40

35 Recommendations for prevention of cyanide exposuresTraining Explanation why cyanide is more significant today than ever before Chemistry of cyanide Identification of cyanide containing fuels - Medical concerns of cyanide Why firefighters cannot merely rely on their past experiences to determine whether or not a particular atmosphere is safe.Equipment Deploy cyanide detection equipment into the field for use at fires.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 35/40

36 Recommendations for prevention of cyanide exposuresCompliance There needs to be enhanced compliance with the existing mandatory mask regulation. - Enhanced compliance will require a cultural change on the part of firefighters. - Company officers must focus on the protection of their members, and ensure that SCBA’s are utilized when necessary and face pieces removed outside the contaminated area when exiting the structure.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 36/40

37 Recommendation for prevention of cyanide exposuresSCBA Training for difficult operations - All personnel need physical training with SCBA to enhance the comfort level of members when engaged in difficult operations such as: - climbing ladders operating on roofs operating in confined spaces - communicating on airSCBA Air Management SCBA alarms activated during initial extinguishment and during overhaulAir management needs to be addressed which would incorporate SCBA alarms going off during entry times, during overhaulDRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 37/40

38 Recommendations for Prevention of Cyanide PoisoningPost-Fire Decontamination Wash turnout gear after each fire - Shower and change their clothes - Issue second set of gearWashing of SCBA masks before placing back in mask bag.Prevention of gear inside station especially bunk rooms.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 38/40

39 Recommendations for Prevention of Cyanide PoisoningFire Research How much cyanide is generated at fire scenes?- What conditions yield higher verses lower concentrations of CN? Whether CN that is released in a fire remains localized (in a area around the fuel that is off gassing) or does it spread out throughout the building? Is CN released only under certain fire conditions or is it released more commonly whenever CN containing products burn?DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 39/40

40 Recommendations for Prevention of Cyanide PoisoningPublic Education General public, media and legislators need to be educated about the dangers of smoldering and burning plastics and other cyanide containing fuels. - Public needs to know the dangers associated with CN may be present before the presence of any flames and possibly incapacitated by the invisible gases during the incipient stage which could prevent them from escaping.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 40/40

41 Clark County Fire Fighter FatalityCrews operating at the scene of a commercial dice factory fireHeavy smoke and fire conditionsAll crews are instructed to utilize standard PPESCBA are used by all respondersClark County Las Vegas Nv.We have been trained with tactical theory from yesterday. With the addition of plastics, synthetics, and natural fibers these materials will burn hotter and the toxic by-products that are given off during and after the fire are more deadlier.I use the analogy is that our bodies are like sponges. We will absorb vapors and gases into our systems some of which will be excreted and some unfortunately will not.More emphasis needs to be place on fire behavior, smoke reading, toxicology, building construction, health and safety.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 41/40

42 Clark County Fire Fighter FatalityWhat are some of the hazards present?As a Incident Commander, what types of injuries or conditions may you expect?Smoke- particulate matter, heated gases, irritants such as hydrochloric acid, sulfur dioxide, ammoniaAsphyxiates such as carbon dioxide and toxins such as hydrogen sulfide and hydrogen cyanide.Both CO and CN are very likely to be two of the most prevalent gases.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 42/40

47 ELECTROCHEMICAL SENSORSBased on a chemical reaction that produces an electrical response/signal.The more gas that is present, the larger the signal that is generated by the sensor.This signal is directly proportional to the gas that is present.DRAEGER SAFETY • Hydrogen Cyanide in Fire OperationsMarch 28, • 47/40